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ON COMPUTER/SCANNED <br /> Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator C M o 0 <br /> APPLICATION FOR - LAND USE - PERMITS <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and y <br /> locate,-,'as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the M <br /> Burnett County Land Use Ordinance,Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> N v oC <br /> regulations of the State of Wisconsin. y <br /> L c <br /> OWNER(Please Print) Contractor or Surveyor or Agent o :3 <br /> Address Address <br /> DA jj 4-1 il I-Y - 9 <br /> City,State, Zip Code City,State,Zip Code <br /> Telephon Telephone ,) a <br /> j 3, <br /> n <br /> Emergency/Fire No. and Road Name ' <br /> Legal Description (as indicated on tax statement) o r- <br /> o <br /> Permit(s) Applied for: o °_ <br /> Dwelling Addition Filling/Grading Camping Unit <br /> z o <br /> Accessory Building Sanitary Privy Subdivision ° <br /> Garage <br /> f r � <br /> Structure Use: A q ` , _ r <br /> 0 <br /> (family home/cabin, garage, addition, etc.) <br /> 1A <br /> DIRECTIONS FOR PLOT PLAN DRAWING: (Aerial or top view) M <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). o <br /> 2. Show the location of the well (W), septic tank (ST), and drainfieid (DF). 3 <br /> 3. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building Z a, <br /> measurement to the ordinary high water mark of lake,stream, or river. o a <br /> 4. If separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and m ti y <br /> dated by the owner. <br /> C " <br /> PLOT PLAN m <br /> CtvIdr riOrf r #;7 400 y S 1f Lac� b� we /34 � C��t >°r�he— �� . <br /> cn <br /> CD <br /> O <br /> 7 <br /> (0 <br /> v � <br /> 1 � <br /> z <br /> J <br /> 1 <br /> I <br /> �D o r . v D <br /> m. ay a � 7 <br /> CD< R y <br /> 4 <br /> Z o(D —p' : z : <br /> f T (n <br /> c r <br /> .5 L7 i <br /> g : <br /> a C <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o (D ` <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informa- <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. I <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- N <br /> placation. I agree to permit county officials charged with administering county ordinances or other authorized person to have N <br /> access to the above described premises at any reasonable time for the purpose of inspection. w g o <br /> N A to <br /> SIGN HERE LA e, <br /> (signature of owner or build' g co racto (date) <br /> ZONING ADMINISTRATOR <br /> JwN N ON��� <br /> TOWNSHI ERMITS MAY BE REQUIRED v, 0 cn 0 <br /> 88888988i <br />